MONITORING REPORT South 24 Parganas Cycle 1: July - November 2016 West Bengal, India DATA INFORMED PLATFORM FOR HEALTH
MONITORING REPORT
South 24 Parganas, West Bengal, India Cycle 2: July – November 2016
TABLE OF CONTENTS LIST OF TABLES ...... II LIST OF ABBREVIATIONS ...... III
1. INTRODUCTION ...... 1 2. METHODS ...... 2 3. FINDINGS ...... 2 3.1 Utilisation of data at district level ...... 2 3.1.1 Status of data utilisation ...... 2 3.1.2 Challenges in data utilisation ...... 3 3.1.3. Proposed solutions ...... 3 3.2 Interaction among stakeholders ...... 4 3.2.1 Interaction between health and non-health departments ...... 4 3.2.2 Interaction between the health department and NGOs ...... 4 3.2.3 Interaction between the health department and private for-profit organisations ...... 5 3.3. Progress with action points...... 7 3.3.1 Action points accomplished ...... 7 3.3.2 Action points ongoing ...... 7 3.3.3 Action points not started...... 8 3.4 Sustainability of the DIPH ...... 10 3.4.1 Data source ...... 10 3.4.2 Facilitators within the district ...... 10 3.4.3 Challenges within the district ...... 10 3.4.4 Possible solutions ...... 10 REFERENCES ...... 11 ANNEXES ...... 12
A.1: DIPH FORMS OF STEP 1 (FORM 1A.1, FORM 1B, AND 1B.1), STEP 4 (FORM 4) AND STEP 5 (FORM 5) ...... 12 A.2: RECORD OF PROCEEDINGS – SUMMARY TABLES ...... 25 A.3: TRANSCRIPTS OF IN-DEPTH INTERVIEWS WITH STAKEHOLDERS ...... 29 A.4: MONITORING FORMAT WITH DEFINITIONS ...... 37 ACKNOWLEDGEMENTS IDEAS Team (LSHTM) DIPH Lead: Dr Bilal Iqbal Avan PI: Prof Joanna Schellenberg Country Team (India – PHFI) Lead: Dr Sanghita Bhattacharyya Research Associate: Dr Anns Issac District Co-ordinators: Mr Sayan Ghosh, Mayukhmala Guha and Antara Bhattacharyya State Partner (West Bengal) State Ministry of Health and Family Welfare West Bengal University of Health Sciences (Prof Bhabatosh Biswas, Vice Chancellor)
i LIST OF TABLES Table 1: Utilisation of data at district level ...... 3 Table 2: Interactions among stakeholders...... 5 Table 3: Progress with action points ...... 8
ii LIST OF ABBREVIATIONS ACMOH Assistant chief medical officer of health ADM Additional district magistrate ANC Antenatal care ANM Auxiliary nurse midwife ASHA Accredited Social Health Activist AWW Anganwadi worker BAM Block accounts manager BMOH Block medical officer of health BPHN Block public health nurse CD Child Development CDPO Child development project officer CINI Child in Need Institute CMOH Chief medical officer of health DAM District accounts manager DEO Data entry operator DHHD Diamond Harbour Health District DIPH Data Informed Platform for Health DMCHO District maternity and child health officer DSM District statistical manager Dy. CMOH-III Deputy chief medical officer of health-III HMIS Health Management Information System ICDS Integrated Child Development Services IEC Information, education and communication IMA Indian Medical Association MCTS Mother and Child Tracking System NGO Non-governmental organisation PHN Public health nurse PHPC Public health programme co-ordinator PMSMA Pradhan Mantri Surakshit Matritva Abhiayan PRD Panchayat and Rural Development S24PGS South 24 Parganas SHG Self-help group SHIS Southern Health Improvement Samity SSDC Sunderban Social Development Centre UNICEF United Nations Children’s Fund VHND Village Health and Nutrition Day
iii 1. INTRODUCTION
Data Informed Platform for Health (DIPH) Cycle No. 2 District South 24 Parganas Health District Duration July – November 2016 Theme Improve the coverage of fourth antenatal check-up Steps Step 1 Assess: Based on the Prime Minister’s safe motherhood programme involved Pradhan Mantri Surakshit Matritva Abhiayan (PMSMA) (MoHFW, 2016a), the DIPH stakeholders assessed gaps in service provision from the District Programme Implementation Plan 2015/16 and the Mother and Child Tracking System (MCTS) (Department of Health and Family Welfare, 2015; MoHFW, 2016b). Theme selection, in consultation with the non-health departments, was to ‘Improve the coverage of fourth antenatal check-up’ for Cycle 2 of the DIPH. As the non-health departments do not maintain data to the theme indicators, the situation assessment only used data from the health department. Step 2 Engage: The primary responsibility for Cycle 2 was with the health department, while the departments of Child Development (CD), Panchayat and Rural Development (PRD) and the district administration shared the supportive responsibilities. Majority of participants were from the health department. The deputy chief medical officer of health- III (Dy. CMOH-III) became the theme leader for Cycle 2. Non- governmental organisations (NGOs) and major private for-profit organisations did not receive an official invitation to take part in the DIPH process. Step 3 Define: The DIPH district stakeholders prioritised action points to achieve the targets based on: service delivery; health information; and finance. They identified ten problems with 60% under ‘service delivery’. They formulated six actionable solutions to address the ten problems, in keeping with cycle duration and capacity of the district administration. Step 4 Plan: The stakeholders developed six action points (and 18 indicators) to achieve the target and assigned responsibilities across departments within a given time frame. All the responsibilities were with the Department of Health and Family Welfare. Step 5 Follow-up: The stakeholders attended two meetings before the Step 5 meeting to facilitate the follow-up of the action plan. Out of the six action points, only two action points (33%) had completed within the specified timeline. The remaining action points received a new timeline. The theme leader monitored the progress through monthly reports (from district personnel responsible for each action point).
1 2. METHODS Sl. Lead among DIPH Data sources Time frame No stakeholders 1 Step 1: Assess Theme leader of the 04 July 2016 Form 1A.1: Data extraction from state and district DIPH Cycle 2 health policy documents Form 1B: Health system capacity assessments Form 1B.1: Sub-district level (block) performance of selected indicators 2 Step 2: Engage Theme leader of the 04 July 2016 Form 2: Engage DIPH Cycle 2 3 Step 3: Define Theme leader of the 04 July 2016 Form 3: Define DIPH Cycle 2 4 Step 4: Plan Theme leader of the 20 July 2016 Form 4: Plan DIPH Cycle 2 5 Step 5: Follow-up Theme leader of the 10 November 2016 Form 5: Follow-up DIPH Cycle 2 6 Record of Proceedings – Summary Tables Recorded by the DIPH June – September Form A.2.1: Record of Proceedings – Summary for research team, South 24 2016 DIPH Step 4 Parganas (S24PGS) Form A.2.2: Record of Proceedings – Summary for DIPH Step 5 7 In-Depth Interviews with Stakeholders Interviewed by the 28 September 2016 Form A.3.1: District accounts manager (DAM) DIPH research team, Form A.3.2: District statistical manager (DSM) S24PGS 29 September 2016 Form A.3.3: Dy. CMOH-III 26 October 2016
3. FINDINGS The monitoring of the DIPH implementation process focused on four themes: 1. Utilisation of data at district level 2. Interaction among stakeholders such as co-operation in decision-making, planning and implementation 3. Follow-up to ensure accomplishment of action points 4. Sustainability perspective by the DIPH stakeholders
3.1 Utilisation of data at district level 3.1.1 Status of data utilisation The DIPH stakeholders adhered to the components of the recently introduced scheme of the Prime Minister’s safe motherhood programme (PMSMA) (MoHFW, 2016a) and identified the theme for Cycle 2 as ‘Improve the coverage of fourth antenatal check-up’. The PMSMA, introduced during June 2016, aims at providing free health check-ups and treatment to all pregnant women across the country (MoHFW, 2016a). The stakeholders utilised data from the District Implementation Plan 2015/16 and the MCTS to assess the gaps in antenatal services (Department of Health and Family Welfare, 2015; MoHFW, 2016b). Development of the theme was in consultation with the non-health departments; however, the non-health departments do not maintain data regarding the identified theme. Compared to Cycle 1, the stakeholders are aware of the significance of data and occasionally they highlighted the health issues with the support of statistical information.
2 “[…]under each step of the cycle, analysis was conducted[…] Previously, we used to conduct a huge analysis for all the indicators after receiving the data from the blocks[…] A streamlining of the data processing happened under DIPH, which is very much needed.” (DSM, S24PGS) 3.1.2 Challenges in data utilisation The challenges of data utilisation also continued to Cycle 2. Timely availability and completeness of data from all relevant departments is still a major concern. Also, data on human resources, trainings conducted and infrastructure are not stored systematically. There is no data-sharing from private providers and NGOs, other than those who enrolled with government programmes. There therefore, needs to be improvement in data-sharing between departments.
“The information from NGOs and private sector, who are involved with government programme can be accessed properly… But data from other registered and non- registered nursing homes are not available. We raised this issue in several meetings. But nothing has happened till now.” (DSM, S24PGS) 3.1.3. Proposed solutions The chief medical officer of health (CMOH) suggested a regular verification of data at block level before sending it for compilation at the district. Also, the monthly review of selected data elements, as part of the DIPH process at district level reproductive and child health meetings, enable the health department to identify gaps. There needs to be similar verification by non-health departments.
Table 1: Utilisation of data at district level Purpose Indicators Response Source of (Yes/No and information proportion) Whether the DIPH A. Selection of the 1. Whether the DIPH cycle Yes1 Form 1B study led to the primary theme for theme selection was based on utilisation of the the current DIPH HMIS data? (Y/N) health system data cycle 2. Whether the DIPH cycle No2 Form 1B or policy directive theme selection used any data at district level for from non-health departments? decision-making? (Y/N) 3. Whether the DIPH cycle Yes3 Form 1A.1 theme selection was based on health policy and programme directives? (Y/N) B. Data-based 4. (Number of action points on 6/6 = 1004 Form 5 monitoring of the which progress is being
1 As per MCTS, percentage of pregnant women received minimum of four antenatal check-ups was 25% in the selected health district (MoHFW, 2016b). This indicates a gap of 75%. (See Form 1.B, Sl. No. 2.1.) 2 The theme selection did not use data from other departments because they do not collect any data on the discussed theme. 3 The present gap analysis focuses on the Prime Minister’s safe motherhood programme (PMSMA), which implies 100% improvement in the coverage of fourth antenatal check-up for all registered pregnant women (MoHFW, 2016a). (See Form 1A.1, Sl. No. 1.) 4 Data monitoring occurred for all six action points during Cycle 2 (August − October 2016). (See Form 5.)
3 action points for monitored by data) / (total the primary theme number of action points for the of the DIPH primary theme of the DIPH) C. Revision of 5. Whether stakeholders No5 Form 4 district programme suggested a revision/addition data elements for to the health system data in the the primary theme given DIPH cycle? (Y/N) of the DIPH 6. (Number of data elements 0/06 Form 5 added in the health database as per the prepared action plan) / (total number of additional data elements requested for the primary theme of the DIPH) D. Improvement in 7. Whether the health system No7 Form 1B the availability of data required on the specified health system data theme as per the given DIPH cycle was made available to the assigned person in the given DIPH cycle? (Y/N) 8. Whether the health system No8 Form 1B data on the specified theme area is up-to-date as per the given DIPH cycle? (Y/N)
3.2 Interaction among stakeholders Facilitating multi-stakeholder co-operation is one of the main objectives of the DIPH. However, the existing bureaucratic framework and rigid hierarchies pose several challenges.
3.2.1 Interaction between health and non-health departments The identified theme falls under the direct responsibility of the health department. Hence, majority of participants are from the health department. The participation from non-health departments is poor. No one from the departments of CD and PRD participated in Steps 4 and 5 Cycle 2 meetings. However, the PRD representative attended Steps 1, 2 and 3 meetings. The health department holds all responsibility for achieving the action points. 3.2.2 Interaction between the health department and NGOs A few NGOs are working in the district; however, they are not part of any decision-making process. The NGO, Child in Need Institute (CINI) is currently working with the district health department and therefore, invited to the DIPH meeting. Their district co-ordinator formally attended the meeting, but did not take part in any discussions.
5The stakeholders could not identify any addition or revision to the health system data in the given DIPH cycle. (See Form 4.) 6 The stakeholders found no relevant data element to be included in the health database as per the prepared action plan. (See Form 5.) 7The data for indicators are not readily available on time from the DSM. In addition, the data on human resources, trainings conducted and infrastructure are not updated timely and stored systematically. These data are from different forms and were incomplete. (See Form 1B.) 8 The latest data (25% for S24PGS Health District based on MCTS key indicators) available during DIPH Step 1 (July 2016) is for May 2016. (See Form 1B, Sl. No. 2.1.)
4 3.2.3 Interaction between the health department and private for-profit organisations The district has a significant share of urban population catered by private for-profit providers. However, there is no interaction between government departments and the private sector on a regular basis. The health department has limited interaction with private providers to provide/renew licences for private clinics/maternity homes.
Table 2: Interactions among stakeholders Purpose Indicators Response Sources of (Yes/No, information proportions) Whether the DIPH E. Extent of 1. (Number of DIPH 86/90 = 95.6 9 Form A.2 study ensured stakeholder stakeholders present in involvement of participation the planning actions stakeholders from meeting) / (total different sectors number of DIPH (health, non-health stakeholders officially and NGO/private invited in the planning for-profit actions meeting) organisations) 2. (Number of 82/90 = 91.1 10 Form A.2 representatives from the health department present in the planning actions meeting) / (total number of DIPH participants in the planning actions meeting) 3. (Number of 3/90 = 3.3 11 Form A.2 representatives from non-health departments present in the planning actions meeting) / (total number of DIPH participants in the planning actions meeting) 4. (Number of 1/90= 1.1 12 Form A.2 representatives from NGOs present in the planning actions meeting) / (total number of DIPH participants in the
9 The participation involved calculating the invitee list and attendant list of Steps 4 and 5 meetings, along with the Record of Proceedings. (See Form A.2.1, Sl. No. C1-C2 and Form A.2.2, Sl. No. C1-C2.) 10 Majority of representatives are from the health department. (See Form A.2.1, Sl. No. C2 and Form A.2.2, Sl. No. C2.) 11 The non-health departments invited are CD-Integrated Child Development Services (ICDS), PRD and district administration. (See Form A.2.1, Sl. No. C2 and Form A.2.2, Sl. No. C2.) 12 NGOs are not formally part of any district-level meeting. However, as CINI works with the district they took part in the meeting. (See Form A.2.1, Sl. No. C2 and Form A.2.2, Sl. No. C2.)
5 planning actions meeting) 5. (Number of 0/90 (Nil)13 Form A.2 representatives from private for-profit organisations in the planning actions meeting ) / (total number of DIPH participants in the planning actions meeting) F. Responsibilities 6. (Number of action 6/6 = 10014 Form 4 assigned to points with stakeholders14 responsibilities of the health department) / (total number of action points for the primary theme of the DIPH) 7. (Number of action 0/6 (Nil)14 Form 4 points with responsibilities of non- health departments) / (total number of action points for the primary theme of the DIPH) 8. (Number of action 0/6 (Nil)15 Form 4 points with responsibilities of NGOs) / (total number of action points for the primary theme of the DIPH) 9. (Number of action 0/6 (Nil)15 Form 4 points with responsibilities of private for-profit organisations) / (total number of action points for the primary theme of DIPH) G. Factors influencing 10. List of facilitating 1. District Form A.3 co-operation among factors magistrate is keen health, non-health and to improve the NGO/private for-profit health status of the organisations to district and achieve the specific actively support
13 None invited from the private sector for the DIPH meeting. They are not formally part of any district-level meeting. (See Form A.2.1, Sl. No. C2 and Form A.2.2, Sl. No. C2.) 14 For each action point, the DIPH stakeholders, based on their responsibilities, assigned a person from the department (health, non-health, NGO and private for-profit organisations) responsible for completing the action points within the designated time frame. The health department personnel were responsible for all six action points. (See Form 4, column: ‘Person responsible’.) 15 There is no action point chosen for NGOs and the private sector. (See Form 4.)
6 action points in the the DIPH given DIPH cycle16 2. Good rapport between the DIPH research team and district stakeholders 3. Presence of an NGO in the district 11. List of 1. The DIPH still Form A.3 challenging factors considered as a health department activity 2. Shortage of staff 3. Timely availability of data and issues with quality
3.3. Progress with action points Almost half of the action points (three out of six) relate to service delivery. The theme leader reviewed the monthly progress reports from the blocks and provided feedback to accomplish the action plan. 3.3.1 Action points accomplished All six action points started during the cycle period, but only two actions points had completed by the Step 5 meeting.
Target low performing block and conduct a meeting on third week to review basic indicators of antenatal care (ANC) such as early registration, third antenatal check-up and fourth antenatal check-up. Secure sanction from state authorities for recruitment of staff for key positions.
The block-wise review of selected indicators achieved more than 100% coverage, indicating that the target set is less than the average. There was a total of ten personnel (data entry operators [DEOs], block public health nurses [BPHNs], and block medical officers of health [BMOHs]) recruited during the cycle period. The recruitment process is still ongoing.
3.3.2 Action points ongoing Four action points are continuing onto the next cycle:
Identify and target high-risk pregnant women (targeting 10% of high-risk pregnant women for service delivery) Plan Village Health and Nutrition Day (VNHD) sessions in convergence mode with participation of the health department, ICDS, PRD, NGOs and self-help groups (SHGs), etc.
16 Extracted from in-depth interviews with stakeholders. (See Forms A.3.)
7 Review planning and execution process of data entry by meeting with DEOs from low performing blocks Evaluate funds allocation and expenditure for community awareness of fourth antenatal check-up by blocks
3.3.3 Action points not started All action points started during the cycle period.
Table 3: Progress with action points Response Sources of Purpose Indicators (Yes/No, information proportions) Are the action H. Action points 1. (Number of primary theme- 6/6 = 10017 Form 5 points planned initiated specific action points initiated for the DIPH within the planned date) / primary theme (total number of primary achieved? theme-specific action points planned within the specific DIPH cycle) I. Action points 2. (Number of primary theme- 2/6 = 33.318 Form 5 achieved specific action points completed within the planned date) / (total number of primary theme-specific action points planned within the specific DIPH cycle) 3. (Number of written 0/019 Form 5 directives/letters issued by the district/state health authority as per action plan) / (total number of written directives/letters by the district/state health authority planned as per action points of the DIPH primary theme) 4. (Amount of finance 0/0 (Nil)20 Form 5 sanctioned for the primary theme-specific action points) / (total amount of finance requested as per action points of the DIPH primary theme) 5. (Units of specific medicine 0/0 (Nil)21 Form 5 provided for the primary theme-specific action points) /
17 All six action points started within the timeline. (See Form 5, Part B, columns: ‘Action points’; ‘Timeline for completion’; and ‘Status of action points’.) 18 Two action points completed as per the action plan. The ‘ongoing’ ones will continue onto the third cycle. (See Form 5, Part B, columns: ‘Action points’; ‘Timeline for completion’; and ‘Status of action points’.) 19 There are no written directive demands as per action plan. However, a letter issued by the district magistrate of S24PGS Revenue District, advised all district health authorities for their support and active involvement in the DIPH. 20 The state government has assigned funds for institutional delivery, ANC check-up incentives for Accredited Social Health Activists (ASHAs) and the ANANDI programme. As a result, there are no demands for additional finance in the action plan. 21 The selected theme did not require procurement of any medicine.
8 (total units of specific medicine requested as per action points of the DIPH primary theme) 6. (Units of specific equipment 0/0 (Nil)22 Form 5 provided for the primary theme-specific action points) / (total units of specific equipment requested as per action points of the DIPH primary theme) 7. (Units of specific IEC 0/0 (Nil)23 Forms 4 and [information, education and 5 communication] materials provided for the primary theme-specific action points) / (total units of specific IEC materials requested as per action points of the DIPH primary theme) 8. (Number of human 10/10 = 10024 Forms 4 and resources recruited for the 5 primary theme-specific action points) / (total human resources recruitment needed as per action points of the DIPH primary theme) 9. (Number of human 0/0 (Nil)25 Forms 4 and resources trained for the 5 primary theme-specific action points) / (total human resources training requested as per action points of the DIPH primary theme) J. Factors 10. List of facilitating factors 1. Active interest of Form A.3 influencing the district magistrate achievements as 2. The selected per action points themes are aligning of the DIPH with the ongoing primary theme26 initiatives in the district 3. Persistent follow- up by the DIPH research team 11. List of challenging 1. Lack of co- Form A.3 factors ordination between different stakeholder departments 2. Delays in implementation of action points 3. Require hand-
22 There are no demands for any equipment for the selected theme. 23 As mentioned in Form 4, under ‘Material resources required’, there is no specific demand for IEC materials in the action plan. (See Form 4.) 24 As per the action plan, there was a total of ten staff recruited (DEOs, BPHNs and BMOHs). (See Form 5, action point 2.1.1.) 25 There is no training for staff suggested by the action plan. (See Form 5.) 26 Extracted from in-depth interviews with stakeholders. (See Forms A.3.)
9 holding by the DIPH research team 3.4 Sustainability of the DIPH The following analysis is from in-depth interviews with stakeholders as well as observations by the DIPH research team. 3.4.1 Data source Timely availability of data is a challenge − updating the MCTS does not occur on a regular basis (MoHFW, 2016b). There is no effective mechanism to ensure verification of data. Data-sharing does not happen between health and non-health departments, NGOs and private for-profit organisations. 3.4.2 Facilitators within the district The DIPH research team could build and maintain a good rapport with stakeholders. The stakeholders are now familiar with the DIPH process and this resulted in better participation. An official letter by the district magistrate ensuring participation of all stakeholder departments. 3.4.3 Challenges within the district Lack of manpower cuts across departments. The DEO is a contractual post in the health department whereas there are no DEOs for CD-ICDS. Time constraint in bringing district-level officers in a common platform is very difficult due to their involvement in several ongoing programmes in the district. The cycle duration – three to four months − is not enough to achieve the target. Availability and quality of data. Though the dependence on the DIPH research team reduced from Cycle 1, the stakeholders still require regular follow-up by the research co-ordinator. Though the interdepartmental co-ordination is improving very slowly, the major share of responsibilities are still with the health department. Involvement of NGOs and private for-profit organisations is unmet. 3.4.4 Possible solutions There is a need to verify the quality of data and implementation of action points. The stakeholders suggested joint monitoring system and combined field visits to facilitate this. To consider themes that involve more participation by non-health departments. To involve sub-district level stakeholders such as BMOHs, BPHNs, child development project officers (CDPOs) during Steps 4 and 5 for better implementation of the action plan.
10 REFERENCES Department of Health and Family Welfare 2015, District Programme Implementation Plan 2015/16, Government of India, South 24 Parganas.
Ministry of Health and Family Welfare (MoHFW) 2016a, Pradhan Mantri Surakshit Matritva Abhiyan, Government of India, New Delhi, viewed on 25 April 2016, www.nrhmhp.gov.in/sites/default/files/files/PMSMA-Guidelines.pdf
Ministry of Health and Family Welfare (MoHFW) 2016b, Mother and Child Tracking System (MCTS), Government of India, New Delhi.
11 ANNEXES A.1: DIPH Forms of Step 1 (Form 1A.1, Form 1B, and 1B.1), Step 4 (Form 4) and Step 5 (Form 5)
Form 1A.1: Data extraction from state and district health policy documents
Document title: PMSMA Guidelines
Date of release: 02 May 2016
Goal as stated Increase in fourth ANC coverage up to 70% (current – 42%) in document:
Action points specified by document
1 Tracking and tagging of pregnant women with ASHA and auxiliary nurse midwife (ANM)
2 To review the action plan provided to ANM in first Saturday meeting and stress given on fourth ANC check-up
3 Responsibility given to health supervisor in monitoring fourth antenatal check-up at home
4 To target the low performing block and conduct a meeting in third week of each month to review basic indicators of ANC such as early registration, three antenatal check-ups and fourth antenatal check-up
5 Review of planning and execution for data entry for timely update of MCTS format − meeting with low performing block to make them understand basics of data interpretation
12 Form 1B: Health system capacity assessments 1. Information about the district
District Information Source Source detail demographic details
1.1 Total area 9,960 District Census http://www.censusindia.gov.in/2011census/dc (square km) Handbook hb/1917_PART_B_DCHB_SOUTH%20TW ENTY%20FOUR%20PARGANAS.pdf
1.2 Total 8,161,961 District Census http://www.censusindia.gov.in/2011census/dc population Handbook hb/1917_PART_B_DCHB_SOUTH%20TW ENTY%20FOUR%20PARGANAS.pdf
1.3 Number of 1,644,815 District Health Eligible Couple Contraceptive Register women in Plan/District reproductive Programme age group (15- Implementation 49 years) Plan 2015/16
1.4 Number of 1,025,679 District Census http://www.censusindia.gov.in/2011census/dc children under Handbook hb/1917_PART_B_DCHB_SOUTH%20TW five years of ENTY%20FOUR%20PARGANAS.pdf age
1.5 Rural 74.4 District Census http://www.censusindia.gov.in/2011census/dc population Handbook hb/1917_PART_B_DCHB_SOUTH%20TW (%) ENTY%20FOUR%20PARGANAS.pdf
1.6 Scheduled 30.2 District Census http://www.censusindia.gov.in/2011census/dc Caste Handbook hb/1917_PART_B_DCHB_SOUTH%20TW population ENTY%20FOUR%20PARGANAS.pdf (%)
1.7 Scheduled 1.2 District Census http://www.censusindia.gov.in/2011census/dc Tribe Handbook hb/1917_PART_B_DCHB_SOUTH%20TW population ENTY%20FOUR%20PARGANAS.pdf (%)
1.8 Population 819 District Census http://www.censusindia.gov.in/2011census/dc density Handbook hb/1917_PART_B_DCHB_SOUTH%20TW (persons/squar ENTY%20FOUR%20PARGANAS.pdf e km)
1.9 Total literacy 77.5 District Census http://www.censusindia.gov.in/2011census/dc (%) Handbook hb/1917_PART_B_DCHB_SOUTH%20TW ENTY%20FOUR%20PARGANAS.pdf
1.10 Female 71.4 District Census http://www.censusindia.gov.in/2011census/dc literacy (%) Handbook hb/1917_PART_B_DCHB_SOUTH%20TW ENTY%20FOUR%20PARGANAS.pdf
1.11 Key NGOs
Name of NGO Contact details
13 1.11.1 CINI Dr. Samir Narayan Chowdhuri, Director, Daulatpur, P.O. Pailan Via Joka, 24 Parganas (S) Pin – 700 104, West Bengal, India Tel: +91 33 2497 8192/8206/8251/8641 Fax: +91 33 2497 8241 Email: [email protected]
1.11.2 Sunderban Social Ranajit Manna, Secretary, Vill: Sultanpur P.O: Krishnanagar Via: Development Centre Ghateswar 24 Parganas(South) West Bengal 743343 India phone : (SSDC) 03174 – 277286
1.11.3 Southern Health MA Wohab, Director, Village: Kanthalia, P.O.: Bhangar, P.S.: Improvement Samity Kashipur, District: South 24 Parganas, West Bengal, India Pincode : (SHIS) 743502 Phone : 0091 3218-270245, Fax : 0091 3218 271969 Email – [email protected]
1.11.4 Sabuj Sangha Ansuman Das, Secretary, Village and P.O.: Nandakumarpur District: South 24 Parganas Pin:743349 West Bengal, Phone: +91 33 2441 4357 Mobile: +91 983 1001655 Email: [email protected]
1.12 Key private for-profit organisations
Name of organisation Contact details
- -
2. Expected coverage for the identified theme
Theme Coverage indicators Current Expected Gap Source status status
2.1 Improve the coverage of 2.1.1 Percentage of pregnant 25.20 100 74.80 MCTS fourth antenatal women received check-up minimum four antenatal check-up
3. Theme:- Improve the coverage of fourth antenatal check-up
Details Sanctioned (2014/15) Available/functional Gap
3.1 Infrastructure
3.1.1 Sub-centres 593 593 0
3.1.2 Primary Health Centres 32 32 0
3.1.3 Block Primary Health Centres 5 5 0
3.1.4 Rural hospital 12 12 0
3.1.5 Sub-divisional hospital 2 2 0
3.1.6 District hospital 1 1 0
14 3. Theme:- Improve the coverage of fourth antenatal check-up
Details Sanctioned (2014/15) Available/functional Gap
3.1.7 Delivery points 32 32 0
3.2 General resources
3.2.1 Finance
3.2.1.a Institutional delivery (Indian rupee) 14,749,000 14,749,0000
3.2.1.b For Janani Shishu Suraksha Karyakaram (Indian rupee) 57,839,000 57,839,0000
3.2.2 Supplies
3.2.2.a Injection Oxytocin 1,920 1,920 0
3.2.2.b Dextrose solution 5% 35,000 35,000 0
3.2.2.c Calcium Carbonate 20,000 20,000 0
3.2.2.d Paracetamol suspension 55,000 55,000 0
3.2.2.e Gentamycin Sulphate 12,000 12,000 0
3.2.3 Technology
3.2.3.a m-health technology 1 1 0
3.3 Human Resources
3.3.1 ASHA 3,158 2,237 921
3.3.2 First ANM 593 576 17
3.3.3 Second ANM 593 447 146
3.3.4 Anganwadi worker (AWW) 10 9 1
3.3.5 Obstetrician and gynaecologist 20 21 -1
3.3.6 Paediatrician 18 14 4
15 Form 1B.1: Sub-district level (block) performance of selected indicators Theme (Cycle 2 S24PGS Health District): Improve the coverage of fourth antenatal check-up Pregnant women Pregnant women Pregnant women Pregnant women Pregnant women First trimester received minimum received minimum received Tetanus received Tetanus received 100 Iron Folic registration to total Sl. No. Block name of three antenatal of four antenatal Toxoid 1 to total ANC Toxoid/2 or booster to Acid tablets to total ANC registration check-ups check-ups registration total ANC registration ANC registration (%) (%) (%) (%) (%) (%) HMIS MCTS HMIS MCTS HMIS MCTS HMIS MCTS HMIS MCTS HMIS MCTS 1 Baruipur 83.9 63.3 51.9 26.1 88.5 90.3 105.6 73.3 88.6 63.0 2 Basanti 76.5 65.1 24.0 2.4 89.5 82.1 101.0 32.3 61.3 29.9 3 Bhangore-I 82.8 69.9 43.2 12.0 89.1 18.4 107.4 16.7 53.8 36.6 4 Bhangore-II 82.5 75.3 51.4 23.1 99.1 99.6 94.5 52.0 96.6 99.6 5 Bishnupur-I 86.1 67.5 56.9 28.8 91.7 83.8 88.1 63.8 75.5 71.9 6 Bishnupur-II 87.2 72.7 52.1 25.5 96.1 79.8 95.3 64.9 76.3 72.3 7 Budge Budge-I 89.5 61.8 73.8 28.8 78.5 98.4 78.0 82.7 73.3 97.9 8 Budge Budge-II 88.9 68.1 75.0 47.3 102.4 87.9 92.0 84.4 90.3 88.7 9 Canning-I 77.5 56.4 62.1 21.8 86.5 75.6 118.9 66.6 79.5 74.3 10 Canning-II 79.4 61.6 61.7 27.2 90.3 85.9 103.0 72.8 62.2 82.7 11 Gosaba 82.7 75.7 37.9 17.6 85.5 79.1 100.0 51.5 81.2 35.2 12 Joynagar-I 88.0 76.2 78.2 48.0 83.0 81.5 102.5 75.6 82.9 93.7 13 Joynagar-II 78.9 75.9 26.6 12.9 86.9 71.9 98.8 45.1 91.8 55.6 14 Kultali 79.1 66.3 74.0 32.4 86.6 89.1 87.2 78.6 89.2 74.0 15 Sonarpur 85.1 71.0 78.2 44.0 86.5 86.8 86.5 83.5 91.7 89.5 16 T.M. 86.0 64.6 68.9 44.7 73.5 81.6 69.3 73.2 70.0 74.2 *Source: Health Management Information System (HMIS) data May 2016/17 status as on: 30 June 2016 and MCTS data status as on 30 June 2016.
16 Form 4: Plan
Theme: Improve the coverage of fourth antenatal check-up
Total number of action planned 6
Responsibilities of different stakeholders
Department of Health and Family Welfare 6
Action points Responsible Indicator Target Timeline stakeholder
1.Service delivery
1.1.1 Target low performing block and Department of Health a. Proportion of early registered pregnant women (%) 9,600 conduct a meeting on third week, and Family Welfare October to review basic indicators of ANC Person Responsible: b. Proportion of pregnant women completed three antenatal 10,550 2016 such as early registration, third BPHN /public health check-ups (%) antenatal check-up and fourth nurse (PHN) antenatal check-up c. Proportion of pregnant women completed fourth 9,000 antenatal check-up (%)
1.2.1 Identify and target high-risk Department of Health October a. Proportion of high-risk pregnant women identified by 1,100 pregnant women (targeting 10% and Family Welfare ASHA and ANM (%) 2016 of high-risk pregnant women for Person Responsible: service delivery) BPHN b. Proportion of new cases of hypertension detected in 400 pregnant women (%)
c. Proportion of eclampsia cases managed during delivery 100 (%)
d. Proportion of pregnant women with severe anaemia 600
17 Action points Responsible Indicator Target Timeline stakeholder
treated at institution (%)
1.3.1 Plan VHND session in Department of Health October a. Proportion of VHND sessions held (%) 3,500 convergence mode with and Family Welfare 2016 participation of the health Person Responsible: b. Proportion of participants for each VHND session 18,800 department, ICDS, PRD, NGOs, BMOH, CDPO, public (%) SHGs, etc. health programme co- ordinator (PHPC) c. Proportion of participants from the health 2,000 department for each VHND session (%)
d. Proportion of representatives from ICDS for each 3,500 VHND session (%)
e. Proportion of participants from PRD for each 500 VHND session (%)
f. Proportion of participants from SHGs for each 280 VHND session (%)
2.Workforce
Department of Health a. Recruitment for DEO, BPHN, BMOH (%) 0 and Family Welfare 2.1.1 Secure sanction from state October authorities for recruitment of staff Person Responsible: 2016 for key positions District Recruitment Cell
3.Supplies and technology
18 Action points Responsible Indicator Target Timeline stakeholder
4.Health information
Review planning and execution Department of Health a. Number of data entry per day by DEO for registered 2,500 process of data entry by meeting and Family Welfare 4.1.1 pregnant women (%) October with DEOs from low performing Person Responsible: 2016 block BMOH b. Number of data entry per day by DEO for registered 3,000 child (%)
5.Finance
Evaluate funds allocation and Department of Health a. Unspent balance for training for community awareness of 0 expenditure for community and Family Welfare 5.1.1 fourth antenatal check-up October awareness of fourth antenatal Person Responsible: 2016• check-up by blocks Block accounts b. Unspent balance for IEC materials for community 0 manager (BAM) awareness of fourth antenatal check-up
6.Policy/governance
19 Form 5: Follow-up
Part A
Theme: Improve the coverage of fourth antenatal check-up
Number of meeting for the respective theme: 2
1. Major stakeholders involved in each meeting
Sl. No. Date Number of participants
Meeting 1 20 July 2016 38
Meeting 2 19 August 2016 48
2. Comparison of key coverage indicator(s) in the DIPH cycle Time 0 Time 1 Time 2 Time 3 Graph
Date May 2016 June 2016 July 2016 August 2016
2.1.1 Percentage of pregnant women received minimum four antenatal check-ups 25.2 28.62 27.5 21.93 View Graph
Part B
Total action points − planned: 6
Total action points – Not started: 0
Total action points – Ongoing not on target: 2
20 Part B
Total action points − planned: 6
Total action points – Ongoing on target: 2
Total action points – Completed: 2
Sl. Action points Indicators Target Progress of Person Timeline Status of Further follow-up No. indicators responsible action suggestions points Timeline Change in responsibility
1. Service delivery
1.1.1 Target low BPHN/PHN October Completed No No a Proportion of early registered 9,600 12,271 performing block 2016 pregnant women (%) and conduct a meeting on third b Proportion of pregnant women 10,550 12,307 week, to review completed three antenatal check- basic indicators of ups (%) ANC such as early registration, third Proportion of pregnant women 9,000 11,511 antenatal check-up c and fourth completed fourth antenatal antenatal check-up check-up (%)
1.2.1 Identify and target BPHN October Ongoing – March No a Proportion of high-risk pregnant 1,100 244 high-risk pregnant 2016 on target 2017 women identified by ASHA and women (targeting ANM (%) 10% of high-risk pregnant women b Proportion of new cases of 400 123 being for service hypertension detected in pregnant delivery)
21 Sl. Action points Indicators Target Progress of Person Timeline Status of Further follow-up No. indicators responsible action suggestions points Timeline Change in responsibility
women (%)
c Proportion of eclampsia cases 100 4 managed during delivery (%)
d Proportion of pregnant women 600 2 with severe anaemia treated at institution (%)
1.3.1 Plan VHND BMOH, CDPO, October Ongoing – March No a Proportion of VHND sessions 3,500 3,340 session in PHPC 2016 on target 2017 held (%) convergence mode with participation b Proportion of participants for each 18,800 18,596 of health VHND session (%) department, ICDS, PRD, NGOs, SHGs, etc. c Proportion of participants from 2,000 2,055 the health department for each VHND session (%)
d Proportion of representatives from 3,500 2,791 ICDS for each VHND session (%)
e Proportion of participants from 500 62 PRD for each VHND session (%)
f Proportion of participants from 280 33 SHGs for each VHND session (%)
22 Sl. Action points Indicators Target Progress of Person Timeline Status of Further follow-up No. indicators responsible action suggestions points Timeline Change in responsibility
2. Workforce
2.1.1 Secure sanction District October Completed No No a Recruitment for DEO, BPHN, 10 100 from state Recruitment Cell 2016 BMOH (%) authorities for recruitment of staff for key positions
4 Health Information
4.1.1 Review planning BMOH October Ongoing – No No a Number of data entry per day by 2,500 2,292 and execution 2016 not on DEO for registered pregnant process of data target women (%) entry by meeting with DEOs from b Number of data entry per day by 3,000 1,997 low performing DEO for registered child (%) block
5. Finance
5.1.1 Evaluate funds BAM October Ongoing – No No a Unspent balance for training for 0 0 allocation and 2016• not on community awareness of fourth expenditure for target antenatal check-up community awareness of b Unspent balance for IEC 0 0 fourth antenatal materials for community check-up by awareness of fourth antenatal blocks
23 Sl. Action points Indicators Target Progress of Person Timeline Status of Further follow-up No. indicators responsible action suggestions points Timeline Change in responsibility
check-up
24 A.2: Record of Proceedings – Summary Tables
Form A.2.1: Record of Proceedings – summary for DIPH Step 4 A. Time taken for each session Session Time allotted Actual time taken Remarks A.1 Briefing 5 minutes 2.35 pm – 2.40 pm Total 25 minutes A.2 Form 4 20 minutes 2.40 pm – 3.00 pm B. Stakeholder leadership B.1 Agenda circulated/invitations sent DIPH research team B.2 Chair of sessions CMOH, S24PHS Health District B.3 Nominee/ volunteer 1. Completing data forms Antara Bhattacharya 2. Presenting summary Sayan Ghosh 3. Theme leader Dy. CMOH-III 4. Record of proceedings Antara Bhattacharya C. Stakeholder participation C.1 Number of Health department 30 CMOH, stakeholders invited Dy. CMOH-III, District maternity and child health officer (DMCHO), District programme co- ordinator, BMOH (12 blocks), PHN (2), BPHN (12 blocks) Non-health departments 2 PHPC, DPO NGO/private sector 1 Co-ordinator, CINI District administration - C.2 Percentage of Health department 93% (28) It was informed by Dy. stakeholder participation Non-health departments 0% (0) CMOH-III that less (to those invited) attendance is due to other priorities (health camps being organised for World Population Day) District administration - NGO/private sector 100% (1) Total 88% (29) D. Stakeholder involvement (Note: Record everyone’s viewpoint; if someone did not raise any concern, record it also) D.1 Issues discussed by CMOH Action points health department Dy. CMOH-III Action points, and representatives person responsible and timeline for Form 4.1 (Cycle 2) indicators BMOH, Kultali Action point 1.6.1 in Form 4.1 (Cycle 2) D.2 Non-health PRD departments ICDS D.3 NGO/private sector - D.4 District administration - E. Responsibilities delegated to non-health departments and NGOs* Type of activities shared ICDS PRD NGO F. Co-operation/communication between stakeholders*
25
G. Data utilisation
H. Suggestion for Developing a Decision-Making guide modification (Note: suggestions with justifications on forms, process) No suggestions *Some of these sections are specific to certain DIPH steps only.
26 Form A.2.2: Record of Proceedings – summary of DIPH Step 5 A. Time taken for each session Session Time allotted Actual time taken Remarks A.1 Briefing 5 minutes 12.30 pm – 12.35 pm (5 minutes) Total time taken 40 A.2 Form 5 20 minutes 12.35 pm – 1.10 pm (35 minutes) minutes B. Stakeholder leadership B.1 Agenda circulated/invitations sent DIPH research team B.2 Chair of sessions District magistrate, S24PGS B.3 Nominee/ 1. Completing data forms Antara Bhattacharya volunteer 2. Presenting summary Antara Bhattacharya 3. Theme leader Dy. CMOH-III 4. Record of proceedings Antara Bhattacharya C. Stakeholder participation C.1 Number of Health department 54 Dy. CMOH-I, -II, -III, stakeholders DMCHO, invited Assistant chief medical officer of health (ACMOH), Superintendent, BMOH, BPHN, PHN, District Programme Management Unit Non-health departments - NGO/Private sector - District administration 3 (Swasthya Karmadhyaksha, Due to other meetings district magistrate, additional going on simultaneously district magistrate – ADM) that day at district magistrate’s office, the district magistrate and ADM attended the Samiti meeting and left early C.2 Percentage of Health department 100% (54) stakeholder Non-health departments 0% (0) participation (to District administration 100% (3) those invited) NGO/private sector 0% (0) Total 100% (57) D. Stakeholder involvement (Note: Record everyone’s viewpoint; if someone did not raise any concern, record it also) D.1 Issues Dy. CMOH-I (acting Data validation by BMOHs is discussed by CMOH) needed health department representatives D.2 Non-health PRD Non applicable departments ICDS Non applicable D.3 NGO/private Non applicable sector D.4 District - administration E. Responsibilities delegated to non-health departments and NGOs* Type of activities ICDS shared PRD NGO Non applicable F. Co-operation/communication between stakeholders* Most communication and decisions are from higher officials since the Samity
27 meeting is also a district review meeting G. Data utilisation Not used H. Suggestion for Developing a Decision-Making guide modification (Note: suggestions with justifications on forms, process) No suggestions *Some of these sections are specific to certain DIPH steps only.
28 A.3: Transcripts of In-Depth Interviews with Stakeholders A3.1: In-depth interview with DAM
IDI details IDI label 111_GSN_AB_28Sep2016 Interviewer Antara Bhattacharya Note taker Antara Bhattacharya Transcriber Antara Bhattacharya Respondent details Date and time of interview 28 September 2016 Name of participant Mrs Rakhi Changder Gender Female Designation DAM, S24PGS Department Health Duration of service in the district 10 years Previous position - Qualification M.Com, CA (Final) Years of experience in present department 10 years Membership in committees pertaining to health None
1. How are health-related decision-making processes under the DIPH happening in your district? Data-based decision-making is being done, and decision-making process has definitely improved. For example, the funds allotted for Janani Shishu Suraksha Karyakaram whether they are correct or not, how much fund should be allotted and for which purpose that we can cross-check through MCTS. It’s not that we are taking all financial decisions based on MCTS or DIPH data, but we can cross-check that whether the utilisation of funds is being done or not, and whether funds are being wasted or not. The purpose for which funds have been given, whether it is being used for that. For fourth ANC, we do not have a specific fund for that, but under Janani Suraksha Yojana funds for fourth ANC-related activities is covered. For fourth ANC check-up the pregnant woman does not get any financial benefit. 2. Are you finding the DIPH process useful? If yes, then which aspects are you finding particularly useful? Follow-up of action plan is important, I think. For example, in case of maternal death, whether all the maternal deaths have been audited that needs proper follow up. This I think is little difficult. 3. What progress through the DIPH have you made to improve the health targets/status in your district (from Cycle 1 to Cycle 2) in the last two DIPH cycles? After the formation of different health districts for S24PGS and Diamond Harbour Health District (DHHD), the accounts related fund monitoring came very much in grip. Since earlier S24PGS was a large district with so many programmes and expenditures for them, management of funds and maintaining accounts data for all the blocks was difficult. The challenge I would say, for the new district that has been formed, some work or programmes that are in pipeline yet can have difficulty in getting funds on time. And since we cannot have inter-district fund transfer that can be a difficulty. Since state has also told us to meet the fund
29 requirements for some health programmes if funds are not immediately available, from the available resources. So always the fund flow will be smooth cannot be expected. But overall the formation of health districts has helped a lot. Since already due to Sunderban area there are many programmes running in the district. So as a result it is difficult to cater to these programmes for the programme officer and DAM.
4. Did the DIPH process help in using data to identify priorities of the district? Yes, prioritisation of health-related problems is being done by us since there is a time factor, so prioritisation needs to be done so that to know which needs to be done earlier. 5. Did the DIPH process lead to any change in the working relationship and interaction between the health department and government non-health departments? Interdepartmental workflow has certainly improved. At the Panchayat level whether it has increased or not, I can say I have seen their involvement in block-level meetings at some places I visited. But a marked level of involvement from Panchayat is not there. I have not noticed any active participation from their end. I think general administration has good working relationship and interaction with health at the district level. At block level there are some short comings.
6. Did the NGO sector achieve involvement through the DIPH process? Yes, the NGOs also have a training schedule e.g. for ASHA training conducted by CINI based on the block achievement list shared in the monthly district meeting (Samity meeting) prepared by UNICEF [United Nations Children’s Fund]. This creates a healthy competition among blocks also to perform better. This was DIPH process and follow-up for blocks is helpful. Some reports are submitted by the NGOs such as ASHA training report is collected by me from them. Also sometimes when UNICEF provides fund for certain programmes such as Integrated Management of Neonatal and Childhood Illness, then we also have to give the report to UNICEF based on the utilisation. We submitted the utilisation report to UNICEF in their specific format. 7. Any suggestions how any of the steps involving the DIPH cycle can be improved (name them)? The circulation of meeting dates for knowledge of all participants should be done seven to ten days earlier. Regarding engagement of all stakeholders, it is fine. For accounts data, I think an online website/database or portal should be developed related to the programmes where expenditure details can be entered and, fund flow and available funds can be checked, very similar to health data. This should be updated and entered at block and district levels. This will be very helpful for account management in the district.
30 A3.2: In-depth interview with DSM
IDI details IDI label 112_GSN_AB_29Sep2016 Interviewer Antara Royghatak Note taker Antara Royghatak Transcriber Sayan Ghosh Respondent details Date and time of interview 29 September 2016; 2.44 pm Name of participant Mr Salil Baral Gender Male Designation DSM, S24PGS and DHHD Department Department of Health and Family Welfare Duration of service in the district 10+ Years Previous position Private sector Qualification BSc, MCA Years of experience in present department 10 years Membership in committees pertaining to health None
1. How are health-related decision-making processes under the DIPH happening in your district?
As such there was no visible distinguish difference can be observed from the DIPH process. It is a process, which was already started in the government system. The document collected during the DIPH process were also maintained before the initiation of the DIPH cycles. But the difference is, now it is become more structured, the block people maintained it properly, so easy to access if needed. Under DIPH a system was built to maintain the process and structured the documentation. Data usage and analysis are going on the same process (started before DIPH). So overall there was no such difference.
Another point is new, under each step of the cycle analysis was conducted. Which is very useful tool. Previously we used to conduct a huge analysis for all the indicators after receiving the data from the blocks. After that we found many times, the analysis of each indicator are not needed. So a streamlining of the data processing is happened under DIPH. Which was very much needed.
2. Are you finding the DIPH process useful? If yes, then which aspects are you finding particularly useful?
The steps of each cycles of DIPH is useful. Out of the five steps ‘follow-up of the action points’ is the most valuable/important step for me. Other steps we are normally follow (not as steps wise) in our regular programme cycles, but regular follow-up of action points is become a challenge to us. Which was done very rigorously first in the ANANDI programme. Now that started in the DIPH programme. Follow-up and sharing of feedback to the stakeholders is very much important. Which is started by reviewing the achievement of action points in each cycle and follow-up for progress in every month. As an example, specific indicator of MCTS uploaded by the block, it is necessary every month to review the development and discuss that in the next meeting and goal set up for upcoming month. Which was not possible every time for all the districts. So quarterly updating the data is a very much needed initiative by DIPH. Because it cannot be visible every month. There should be a monthly monitoring options to monitor the monthly progress.
31 3. What are the key themes covered in the last DIPH cycle?
Fourth ANC updating is the theme for Cycle 2.
4. What progress through the DIPH have you made to improve the health targets/status in your district?
DIPH is a process. Under that process there are developmental tools for supporting action. Those tools are utilised for regular monitoring. Specific follow-up of the issues can give good result. Like fourth ANC, it was not properly followed up and reported. There was a huge gap observed. Which become a challenge for increase institutional delivery. From that aspect increase in fourth ANC it’s important, where ANM supposed to visit her home for antenatal check-up. During that ANM orient them once again on the preparedness for institutional delivery. Which will lead to a safe delivery. Starting from last menstrual period to delivery of a child, the action plan developed through MCTS. That can be follow day by day. ASHA and ANM can motivate her and the family to access the services provided by the government sector. Not to choose the home delivery or service from private nursing homes. All the skilled birth attendant trained nurses and doctors are there to provide quality service. But that monitoring is not done properly. So it create the scope of development for DIPH. And on that DIPH is working.
5. Did the DIPH process help in using data to identify priorities of the district?
There are data available and we used to analysis that. But by the DIPH process more indicator-specific analysis was conducted. This analysis is helping the district to identify the priority areas. Like from those data we can identify the Canning-I, -II and Basanti as under developed, where huge number of home delivery were conducted. On the basis of those data we started constant follow-up, like mothers meetings, community meetings. Extra emphasis given to the concern BMOHs for motivate community towards institutional delivery. From that the institutional delivery increase and that has been monitored by the data sets.
6. Whether data is used in monitoring the progress of the action plan in your district?
Yes, DIPH is a data-based monitoring process. The data are indicator-specific and depending the action plan made to boost up a specific indicators. Which generally found low performing in the MCTS and HMIS. Which are the performance monitoring indicators. So after making action plan for that particular indicator, some performance indicators are identify for monitoring the progress of those action points. Which are mainly numeric data and those are monitored regularly to know the progress of the action points. That also been shared in the monthly reproductive and child health-Management Information and Evaluation System meetings. So all the blocks can know there status.
7. Did the DIPH process lead to any change in the working relationship and interaction between the health department and government non-health departments?
32 To increase institutional delivery, obviously Panchayat is playing a major role. Without the involvement of PRD, this type of the development is not possible. ICDS also having role in school health. They [ICDS] sharing data for identification of pregnant women and school health programme. On that basis we [Department of Health and Family Welfare] have reviewed the progress. In the convergence meeting all the data are shared across the departments. There are many convergence meetings happened under the supervision of district magistrate, like standing committee, vigilance committee, development meeting it is become a common and compulsory across the departments. So all the issues are covered in those meetings.
8. Did the maternal and child health NGO sector achieve involvement through the DIPH process?
The information from NGOs and private sector, who are involved with government programme can be accessed properly. Like data from Community Delivery Centre and Ayushmoti nursing homes are analysed regularly. But other registered and unregistered nursing home data are not accessible to us. We had various meeting and in multiple forums we have raised the issue of the data access from the private sector. But still now that is not happened. If we are consider the institutional delivery data, it can increase 5% to 6% even some cases for up to 10% (in DHHD or Canning subdivision), where huge numbers of private nursing homes conducted institutional delivery. People believes that quality of service is better in private sector then the government-run hospitals. As per the district figures are concern, about 20% of the institutional deliveries conducted at nursing homes, Ayushmoti and Community Delivery Centre. And in the DIPH process also we are not been able to collect those data.
9. Did the private sector achieve involvement through the DIPH process?
Already answered in previous question.
10. What are the challenges faced during the implementation process of the last DIPH cycle? Probe: describe challenges in terms of (BUT not limited to): a. Dedicating time to conduct DIPH b. Availability of data to monitor progress c. Active involvement of different government departments, district administration, NGO and private sector.
After divide into two separate health districts as DHHD and S24PGS, administratively it was easy to manage. But due to lake of human resource the quality of work suffers. Sometime delay also happens due to lake of human resources, as DHHDs post of DSM is vacant.
MCTS portal already separated but HMIS is a common portal, if that also divide into separate district then it will be easy to monitor the district wise performance. Now I am looking into both of the district, so not facing any problem. But in future when DSM appointed at DHHD,
33 then it can create confusion among two DSM for HMIS data uploading.
DIPH should not having a separate reporting system. It should merged with other existing reporting system. Otherwise it will be an extra work load to the DEOs.
Unable to involve the private sector for analysis of the situation at the district level.
11. Any suggestions how any of the steps involving the DIPH cycle can be improved (name them)?
The five steps of DIPH are very scientific approach from planning to monitoring and implementation. But practically it is difficult to follow the process, due to multiple meetings planned under the steps. If the number of meetings can be reduced then it will be a more acceptable to the system.
12. Any suggestions how the DIPH process can be better implemented in your district?
More involvement of other sector is very much needed. If CD and PRD are depends on health department for data access. That is not acceptable. All of them are equally responsible towards the community. So they have to generate the data by them and share with other line departments. The DIPH process should not be dependent on a specific human resource (like DSM). Because that particular post having many others responsibility. So it can have a point person, but responsibility should be distributed across the departments. By that the co-ordination will increase and DIPH can have a better result.
34 A3.3: In-depth interview with Dy. CMOH-III
IDI details IDI label 113_GSN_AB_26Oct2016 Interviewer Antara Bhattacharya Note taker Antara Bhattacharya Transcriber Antara Bhattacharya Respondent details Date and time of interview 26 October 2016 Name of participant Dr Bhaskar Baishnab Gender Male Designation Deputy CMOH-III, S24PGS Department Health Duration of service in the district 1 year Previous position ACMOH Qualification MBBS, DPH Years of experience in present department More than 16 years Membership in committees pertaining to Membership from Indian Medical Association health (IMA) for registered doctors
1. How are health-related-decision-making processes under the DIPH happening in your district? Under DIPH we are using our data to prioritise. In a resource poor district like S24PGS we have to prioritise and target specific agenda so that with low resources we can reach maximum people and those areas where it is maximum needed. So this has been helped by DIPH. 2. Are you finding the DIPH process useful? If yes, then which aspects are you finding particularly useful? All the steps are important. Because the situation analysis is according to the performance report and manpower data, human resources status. Prioritisation is where it is most needed. Then developing action plan based on who are the stakeholders and how to approach the manpower resources most effectively and then follow up of what we have done. First situation analysis and then prioritisation is more important. 3. What progress through the DIPH have you made to improve the health targets/status in your district (from Cycle 1 to Cycle 2) in the last two DIPH cycles? In institutional delivery still there are lots of areas where lot of home deliveries are occurring per block. More than 1,000 home deliveries are there in almost three or four blocks. So these blocks need to be prioritised and the mothers to be reached to give them the message that they should come for institutional delivery. Also immunisation is an important area where more efforts have to be given to identify and target the missing children who cannot be registered for immunisation. This can be for many different reasons and also this represents a major section of missing children from immunisation schedule. To track these missing children no record or line list is there or capturing of data is done anywhere.
35 4. Did the DIPH process help in using data to identify priorities of the district? Yes, some places have the resources but the performance is not so up to the mark and some places are there where human resources are not being utilised up to the maximum level. So after the situation analysis this can be identified and used to help in identifying the priorities. 5. Whether data used from ICDS was for monitoring the progress of the action plan in your district? Yes, it was being done and now it is followed more effectively. We use the data for analysing whether the target is being fulfilled and then we fix some target for the service providers and then we analyse their performance and we set them a new target. 6. Did the DIPH process lead to any change in the working relationship and interaction between the health department and government non-health departments? It has helped to some extent because convergence was already there but this DIPH has improved it little more. Because convergence was there but sometimes the other departments were reluctant. During this DIPH process they became more interested and they participated. It helped in data-sharing between inter-departments. It was there but DIPH process enhanced it. 7. Did the maternal and child health NGO sector achieve involvement through the DIPH process? NGOs were not directly involved. And private sector is not much involved in this district. 8. What are the challenges and opportunities faced during the implementation process of the last DIPH cycle? DIPH process challenge is we should be more vocal. DIPH process is being done within few stakeholders at district level. So we have to involve the block-level and grassroots-level stakeholders more. Because still BMOH and block-level stakeholders are not taking much interest as we thought they would take. We can call ACMOH also at least subdivision level. The ACMOH level tier is little underutilised since we directly call the BMOHs for the meetings. But as per norm first sub- divisional meeting then the ACMOHs will represent their respective subdivisions. So we can try this in DIPH where we involve the ACMOHs and the ACMOHs call the meetings of the blocks under their subdivision. ACMOH then should come and tell the district what they have done. So this thing, involvement of the ACMOHs we can start in the DIPH process. 9. Any suggestions how any of the steps involving the DIPH cycle can be improved (name them)? Involvement of ACMOHs – the middle tier for the meetings. We are directly calling the BMOHs but if ACMOHs call the BMOHs and we go over there for the meeting. Later ACMOH come to the district and gives their feedback for respective blocks it will be better.
36 A.4: Monitoring Format with Definitions A.4.1: Monitoring framework27
Purpose Indicators Definition Sources of information I. Utilisation of data A. Selection of the 1. Whether the DIPH cycle theme Form 1B: Health at district level primary theme for the selection was based on HMIS data? system capacity Whether the DIPH current DIPH cycle (Y/N) assessments study led to the Health system data: statistical utilisation of the health information collected either routinely system data or policy or periodically by government directive at district institutions on public health issues. level for decision- This includes information related to making? provision and management of health services. This data can be from the health department and/or non-health departments In the West Bengal context, the main data sources will include HMIS and MCTS 2. Whether the DIPH cycle theme Form 1B: Health selection used any data from non- system capacity health departments? (Y/N) assessments Non-health departments: government departments, other than the health department, which directly or indirectly contributes to public health service provision In the West Bengal context, this includes PRD and CD 3. Whether the DIPH cycle theme Form 1A.1: Data selection was based on health policy extraction from and programme directives? (Y/N) state and district Health policy: refers to decisions that health policy are undertaken by the documents state/national/district to achieve specific health care plans and goals. It defines a vision for the future which in turn helps to establish targets and points of reference for the short- and medium-term health programmes Health programme: focused health interventions for a specific time period to create improvements in a very specific health domain In the DIPH West Bengal context: any health-related directives/guidelines/government orders in the form of an official letter or circular issued by the district/state government
27For prototyping in West Bengal, India, there is only one primary theme selected for each DIPH cycle. HMIS including MCTS data, health policy/programme directive or both. The action points are on the requirements for achieving the primary theme of the given DIPH cycle. The prioritisation of the action points is on the feasibility as per stakeholder’s decision. The monitoring plan of any given DIPH cycle is on: (i) health system data, e.g. from HMIS and health policy/programme documents from which the theme-specific information is from Form 1A.1; and (ii) monitoring the progress of action points using the specified DIPH format.
37 B. Data-based 4. (Number of action points on which Form 5: Follow-up monitoring of the progress is being monitored by data) action points for the / (total number of action points for primary theme of the the primary theme of DIPH) DIPH Action points: a specific task taken to achieve a specific objective In DIPH context: a specific action, arisen from the stakeholder discussions during Steps 3 and 4, to achieve the target of the given DIPH cycle C. Revision of 5. Whether stakeholders suggested a Form 4: Plan district programme revision/addition to health system data elements for the data in the given DIPH cycle? (Y/N) primary theme of the 6. (Number of data elements added Form 5: Follow-up DIPH in the health database as per the prepared action plan) / (total number of additional data elements requested for the primary theme of the DIPH) Data elements: operationally, refers to any specific information collected in the health system data forms, pertaining to all six World Health Organization health system building blocks (demographic, human resources, finance, service delivery, health outcome, governance) D. Improvement in 7. Whether the health system data Form 1B: Health the availability of required on the specified theme as system capacity health system data per the given DIPH cycle was made assessments available to the assigned person in the given DIPH cycle? (Y/N) Assigned person: as per the cycle- specific DIPH action plan; this can be the theme leader, DSM, or any other stakeholder who is assigned with the responsibility of compiling/reporting of specified data 8. Whether the health system data on Form 1B: Health the specified theme area is up-to-date system capacity as per the given DIPH cycle? (Y/N) assessments Up-to-date data a) If monthly data, then the previous complete month at the time of Step 1 of the DIPH cycle b) If annual data, then the complete last year at the time of Step 1 of the DIPH cycle II. E. Extent of 1. (Number of DIPH stakeholders Form A.2: Record Interactions among stakeholder present in the planning actions of Proceedings – stakeholders: co- participation meeting) / (total number of DIPH Summary Table operation in decision- stakeholders officially invited in the making, planning and planning actions meeting) implementation Participants in Steps 4 and 5 Whether the DIPH DIPH stakeholders: public and private study ensured sector departments, organisations and involvement of bodies relevant for the specific cycle of stakeholders from the DIPH different sectors Officially invited: stakeholders (health, non-health and formally being invited to participate for NGO/private for-profit the specific DIPH cycle
38 organisations) In the West Bengal context, for example: Public sector stakeholders: Department of Health and Family Welfare; PRD; and CD Private sector stakeholders: NGOs; nursing homes; and large hospitals owned by private entities 2. (Number of representatives from Form A.2: Record the health department present in the of Proceedings – planning actions meeting) / (total Summary Table number of DIPH participants present in the planning actions meeting) Participants in Steps 4 and 5 3. (Number of representatives from Form A.2: Record non-health departments present in of Proceedings – the planning actions meeting) / (total Summary Table number of DIPH participants present in the planning actions meeting) Participants in Steps 4 and 5 4. (Number of representatives from Form A.2: Record NGOs present in the planning of Proceedings – actions meeting) / (total number of Summary Table DIPH participants present in the planning actions meeting) Participants in Steps 4 and 5 5. (Number of representatives from Form A.2: Record private for-profit organisations of Proceedings – present in the planning actions Summary Table meeting) / (total number of DIPH participants present in the planning actions meeting) Participants in Steps 4 and 5 F. Responsibilities 6. (Number of action points with Form 4: Plan assigned to responsibilities of the health stakeholders department) / (total number of action points for the primary theme of the DIPH) 7. (Number of action points with Form 4: Plan responsibilities of non-health departments) / (total number of action points for the primary theme of the DIPH) 8. (Number of action points with Form 4: Plan responsibilities of NGOs) / (total number of action points for the primary theme of the DIPH). 9. (Number of action points with Form 4: Plan responsibilities of private for-profit organisations) / (total number of action points for the primary theme of the DIPH) G. Factors 10. List of facilitating factors Form A.3: In- influencing co- 1. Depth Interview operation among 2. with Stakeholders
39 health, non-health 11. List of challenging factors Form A.3: In- and NGO/private - 1. Depth Interview for-profit 2. with Stakeholders organisations to achieve the specific action points in the given DIPH cycle III. Follow-up: H. Action points 1. (Number of primary theme- Form 5: Follow-up Are the action points initiated specific action points initiated within planned for the DIPH the planned date) / (total number of primary theme primary theme-specific action points achieved? planned within the specific DIPH cycle) I. Action points 2. (Number of primary theme- Form 5: Follow-up achieved specific action points completed within the planned date) / (total number of primary theme-specific action points planned within the specific DIPH cycle) 3. (Number of written Form 5: Follow-up directives/letters issued by the district/state health authority as per action plan) / (total number of written directives/letters by the district/state health authority planned as per action points of the DIPH primary theme) 4. (Amount of finance sanctioned for Form 5: Follow-up the primary theme-specific action points) / (total amount of finance requested as per action points of the DIPH primary theme) 5. (Units of specific medicine Form 5: Follow-up provided for the primary theme- specific action points) / (total units of specific medicine requested as per action points of the DIPH primary theme) 6. (Units of specific equipment Form 5: Follow-up provided for the primary theme- specific action points) / (total units of specific equipment requested as per action points of the DIPH primary theme) Equipment: technical instruments, vehicles, etc. provided to achieve the DIPH action points 7. (Units of specific IEC materials Form 4: Plan provided for the primary theme- specific action points) / (total units of Form 5: Follow-up specific IEC materials requested as per action points of the DIPH primary theme) 8. (Number of human resources Form 4: Plan recruited for the primary theme- specific action points) / (total human Form 5: Follow-up resources recruitment needed as per action points of the DIPH primary theme) 9. (Number of human resources Form 4: Plan
40 trained for the primary theme- Form 5: Follow-up specific action points) / (total human resources training requested as per action points of the DIPH primary theme) J. Factors influencing 10. List of facilitating factors Form A.3: In- the achievements as 1. Depth Interview per action points of 2. with Stakeholders the DIPH primary 3. theme 11. List of challenging factors Form A.3: In- 1. Depth Interview 2. with Stakeholders
41 Find out more at ideas.lshtm.ac.uk The Data-Informed Platform for Health is a project implemented in collaboration between the IDEAS project, the Public Health Foundation of India and the West Bengal University of Health Sciences.
The IDEAS project is based at the London School of Hygiene & Tropical Medicine and works in Ethiopia, Northeastern Nigeria and India. Funded by the Bill & Melinda Gates Foundation, it uses measurement, learning and evaluation to ind out what works, why and how in maternal and newborn health programmes.
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Bilal Avan - Scientiic Lead [email protected] -- Joanna Schellenberg- IDEAS Project Lead [email protected]
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Published by he London School of Hygiene & Tropical Medicine Copyright IDEAS 2017